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Claim Auditor
Claim Auditor
Job Description
Job Description
Title: Claim Auditor
Reports to: Claims Training Supervisor
Department: Claims/Operations
Direct Reports: No
Exempt Status: Non-Exempt
Job Purpose
The Claim Auditor is responsible for conducting weekly comprehensive audits for examiners to ensure claims processes are being followed as outlined by the department and provide direct feedback, support, and necessary coaching based on results.
Essential Job Functions
Essential Job Functions
- Perform detailed audits of loss reports and call interactions for all examiners, identifying discrepancies, operational opportunities, and quality concerns
- Identify, document, and communicate audit findings by preparing comprehensive reports for leadership, including key trends and call quality insights
- Evaluate claim handling and call performance through a structured scoring system; document results and deliver clear, actionable feedback to employees verbally and/or in writing
- Facilitate coaching sessions with examiners to ensure all quality and customer service standards across both claims processing and call handling
- Work directly with the training team to create and develop ongoing training materials and skill refinement plans for the department based on audit and call QA results
- Participate in calibration sessions with examiners and department leadership to ensure consistency in audit and call QA scoring
- Track and analyze performance results for monthly scorecards, department KPIs, and call quality metrics
- Provides support operations which includes inbound call handling and claim processing
- Serve as a mentor and subject matter resource for the department, offering guidance on claim handling and customer interactions
- Maintain a continual knowledge of products and services to ensure compliance with all regulations
- Identify root causes of recurring issues within claims processes and propose effective solutions to management to mitigate risks
- Perform other duties as assigned
Minimum Qualifications
- Minimum 1-2 years of relevant experience in quality assurance or quality monitoring, within a call center environment
- Minimum 1-2 years customer service call center environment strongly preferred
- Proficiency in desktop MS applications – Outlook, Excel, PowerPoint
- Claims Adjusters License (preferred)
- Effective presentation, planning, and oral and written communication skills
- Works well independently and effectively manages their time to meet all established deadlines
- Must be highly flexible, and able to handle and manage a high degree of change
- Demonstrates a high commitment to quality and has strong attention to detail
- Strong customer service acumen with hyper-focus on the customer experience
- Able to evaluate employee progress to ensure that the business needs of the department are being met.
- Maintain high and consistent production level as assigned
The information contained herein is not intended to be an all-inclusive list of the duties and responsibilities of the job, nor are they intended to be an all-inclusive list of the skills and abilities required to do the job. Management may, at its discretion, assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons.
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